04090113CITY OF CUPERTINO
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INFORMATIOI
BUILDING DIVISION PERMIT
�ONTRA. OR .�
BUR.DINGADDRESSt
PALISADE BUILDERS INC
PERMIT 11"b4090113
19503 STEVENS
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALKA STREET
04/20/200S
NE:
SANITARY NO. CONTROL NO.
650)470-4700
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CON RACrOR'S DECLARATION
]orb Description
P
1 hemby Aline that 1 Am licensed under provialoru of Chapter 9 (commencing
with Section 7000) of Division 5 of du Business and Profession Code. and my license Is
infuufame and effect. sis80y6
NEW CONDO -1506 SQ. F.T.
Lkena Clay Lic.
Date M' 2� PA •EN
7 •
ARCHITECTS DECLARATION
TS DECLARATION
I understand my plans Nall he a pts li rocartls
Licensed Professions(
OWN DER DECLARATION
1 hereby .('firm Inn 11. exempt from the Contractors License Lew for the
mexe
following mama. (Suitt 7(n Business and Code: Any city or county
s7,
w. dedull
m mash ttructuro
which mquiros •permit to caMruse alter, impnt
fenve, h Immail i ed
prior e, its s the do applicant for such permit m files signal mtentem
atmnt
Sq. Ft. Floor Area
-
Valuation
licensed p in Conuamfa((someWo(Chapter)or
dwhcimigwi
(commencing mitt Station IDn of Division 5 the ex cosi vi Cndc)of
S=Iion7"the )ofDitiomo(of
$174334
on. Any pluton of
M alleged exception. Any
d aged
Net he 4 exempt ttemfrom and site
APN Number
Occupancy Type
per it be
l
70315 by any applicant fora permit subjects site applicant m •civil penalty of
not mom than five hundred dollen ($.500).
Out nta
❑ I, u Owner of W pmpemy. w my empleycet withwages u th k ante wmpenudon,
Required Inspections
will do the wokkmdlhemrctum 6notlatendedorofome forsale(Sec. 7Ua, BLW=
and Profusions Code: The Cmurmh License Law does nal apply m an owner of
9 P
P.Pertywho bulldsorimpawa Marine. and whoduessuch work himself m Wough Mia
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own employes, provided than such improvements am not intended croRered forake. 11',
however, the building or Improvement Is sold within one you of completion. dm owner.
Wilder will have Ne burden of proving that he did not build or Improve for purpose of
sale.).
❑ 1, a Owner of the property, Am exclusively contracting with licensed contractors m
common the project (Sec. 70". Business and Profession Cade:) The Contsaafs Li -
cave law does not "ply m an owner of property who wilds or improves ttemon. and,
who contracts for such projects with t convator(U licensed pursuant b the ConsactoYs
License Law.
I am exempt under See. ,B&PC for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
I berohy.Rune under penalty of perjury oro of site following declaration:
'
1 haw and will maintain a Certificate of Conant m alf-insum for Wmlwf&Conpsn-
sation, u provided for by Section 7700 of Ne Labor Code. for du performance of the
won for which this permit is issued.
❑ 1 haw and will maintain WorkcYs Compensation Insurance, u sequined by Section
7700 of Ne Calmer Code, for the performance of the work for which thin permit is issued.
My Wmkoe. Compensedon Insurance camier and Policy number Am:
Carrkr. ;04)Ae57A ->/n C Policy No.: 0 S33°
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thtsactl" need not uncompleted If Ile permit it forone hundred dollen ($1040
or Mss)
1 cartify Net in the performance of the work for which this permit ts isaed, l shall nal
'
employ any person In my manrcr m u u become subject litho Worker' Compenwilm
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject m the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit be deemed revoked.
CONSTRUCTION LENDING AGENCY
I bereby Arlon that them u a convection lending aarcy for the performance of
the work for which this Permit u issued (Sec. 7(191. Civ. C.)
Lendees Nate
I.Andefs Address
I artily dial I have mad this application and state the, the move information Is
comect I agree m comply with all city ad county ordinances and main laws m W ng to
building construction. and bmaby amhoda mpmxnums of this city m enter upon the
.hove-Wouke u•A property for inspection purposes
(We) Agree In an, indemnify and keep harmless the City of Cupcmim again
liabilities. judgments, cuts and expenses which may in my way wcem Against aid City
In consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type Of Roof
Signature ofApplicanUCAusactor Dam
I} ZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant nom or handle huardous material
As enfined by the Cupertino Municipal Code, Chapter 9.11. and Me Health and Safety
Code, Sccfine 25572(A)7
❑ Ya
All roofs shall he inspected prior to any roofing material being installed.
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future wilding Occupant us, equipment or devices which
II haurdnns air con smmants As defined by site Bay Amo Air Quality Management
all new materials for inspection.
District?
❑Yns'
I have mad the wrandous maunlalsrequlmments under Chman,6.95 ofthe Califor.
nia Hc.lth&Safety Cod ,S.O.m M505.25573.d25534.lunJcrstsndthatlfdu wilding
Jou not currently haw a tenant. thin It u my rosponalhility, In notify the occupant of the
myalroments which mumt he met prior In issuance of a CeNncate of Occupancy.
Signature of Applicant Date
2rate
All roof coverings to be Class "B" or better
Oweerarau(hod . en,